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Dr. Luc Tambeur
Coronary artery
bypass grafting
CABG - OPCAB
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Coronary artery disease
Definition:
Narrowing of the coronary arteries
Caused by thickening and loss of elasticityof the arterial walls
Limiting blood flow to the myocardium
Flow reserve (effort)At rest
Occlusion
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Coronary artery disease
Morphology and processes: Focal intimal accumulation of lipids, blood elements,
fibrous tissue, calcium etc. with associated changes
in the media Plaque
Stenosis
Regression of plaque and collateral formation
Plaque rupture and thrombosis Usually affects multiple coronaries simultaneously,
proximally and at bifurcations
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Myocardial infarction
Imbalance between oxygen supply and
demand
Myocardial necrosis starts after 20 minutes Border zone
Reperfusion within 3-4 hours can limit the
extent of myocardial necrosis
Scarring. LV systolic and diastolic dysfunction.
Chronic heart failure.
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Diagnosis
Symptoms: Angina pectoris, acute
myocardial infarction, chronic heart
failure, sudden death, incidental findingon ECG
Noninvasive tests to identify and quantify
CAD and sequelae: ECG, CXR, Labs,Exercise testing, Nuclear scans,
Echocardiography, CT (Ca++)
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Diagnosis
Associated conditions
Atherosclerosis: carotids, PAD
Definitive diagnosis: extent, distributionand severity of anatomic coronary artery
disease Coronary angiography
New modalities: CT (MRI)
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Coronary angiography
Grading of stenoses:
Moderate: 50% diameter = 75% cross-
sectional area loss Severe: 67% diameter = 90% cross-
sectional area loss
Distribution: Single system / two system / three system
Left main
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Coronary anatomy
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Indications for surgery
Comparative benefit of surgery relative to notreatment / medical treatment / PCI
Enormous variability in CAD, impacting on risk
calculation patient-specific predictions General indications:
Left main or left main equivalent
3 system disease
2 system disease with severe prox. LAD and LVEF< 50% or ischemia on non-invasive testing
1 or 2 system disease with large area of viablemyocardium and high-risk criteria
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Bypass grafting
Full sternotomy and CPB (HLM):
CABG
Full sternotomy, no CPB:
OPCAB
Small sternotomy, parasternal access,thoracotomy, with or without CPB:
e.g.MIDCAB
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Bypass grafting
CABG = Golden standard and still most
widely used (STS database 80%)
Objective: complete revascularisation bybypassing all severe stenoses in all
affected coronary branches with 1-1.5
mm diameter Most widely used conduits: LIMA, RIMA,
SVG, radial artery, gastro-epiploic artery
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Conduits
LIMA / RIMA
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Conduits
SVG
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Conduits
Radial
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Conduits
Gastro epiploic
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Conduit configurations
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Endarter
ectomy
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CABG
Median sternotomy
Conduit harvesting
Heparin, cannulation and CPB with mild to moderate
hypothermia Cross-clamping of the aorta and cardioplegia
Distal anastomoses. Rewarming started.
Cross-clamp removed. Proximal anast. using a partially
occluding clamp. Clamp removed. De-airing. CPB discontinued, cannulae removed, protamine.
Pacing wires, drainage tubes, hemostasis and closure.
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OPCAB
Attempt to maintain normothermia
Median sternotomy
Conduit harvesting
Heparin. Pacing wires. Maneuvers to maintain hemodynamic stability
(Trendelenburg, table, R pleura,.)
Pericardial sling
Luxation. Stabilisation. Distal anastomoses with or
without shunting. Proximal anastomoses. Protamine.
Chest drains. Hemostasis. Closure.
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Not discussed
IABP and other support devices
Emergency surgery
Redo surgery
Other modalities of bypass grafting:MIDCAB, robotic surgery,
Adjunctive surgical treatment: TMLR,growth factors, cell transplantation
Combined surgery
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Results
Early mortality can be predicted, using riskstratification models (Euroscore, STS)
Time-Related Survival, generally:
1 month: 98% 1 year: 97%
5 year: 92%
10 year: 81%
15 year: 66%
NB: 25% of early and late deaths are notrelated to CAD or CABG
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Time Related Survival
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Results
Freedom from angina: 60% at 10 years
Freedom from AMI: 86% at 10 years
Freedom from sudden death: 97% at 10 years
80% of patients are working 1 year postop.
Graft patency: LIMA (to LAD) 90% at 10 and 20 years.
Radial artery 80% at 7 years
Gastro-epiploic artery 60% at 10 years
SVG 50-60% at 10 years, 80% to LAD
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